If the government insists on 3 per cent efficiency savings in hospital costs, next winter will be disastrous, says Simon Walford

Recently I had the experience of being famous for five minutes. Appearances in the local media made me appreciate the pressure on those constantly in the limelight, and the difficulty of getting across a simple message.

The media were entitled to know why the NHS in Wolverhampton was so disrupted over the holiday period and I was keen to relay two messages - that it was inevitable, and that proposals for further cuts were likely to turn a crisis into a disaster next winter.

What evidence is there that such a systematic failure in the provision of emergency services was inevitable? In Wolverhampton we started the winter with 37 fewer medical beds than last year: 20 had been reluctantly given up in accordance with a local service plan between the health authority and social services for elderly care, which envisaged additional support in the community and other rehabilitation facilities reducing the need for acute hospital services. And a small acute admission assessment ward with 17 beds has been closed for months to offset recruitment difficulties. In compensation, we have increased the number of surgical beds by 20 and managed occupancy very efficiently.

We monitor an acute bed pool of about 510 beds, which broadly contains all the acute medical and elderly care beds, and all the emergency and elective beds for orthopaedic, surgery and trauma patients. Research shows that if such a bed pool has an occupancy above 85 per cent at midnight, then the risk of disruption to patient admission increases as occupancy rises. In previous years, occupancy has been around 85 per cent. But since early November, we have regularly seen levels of above 95 per cent.

No room for manoeuvre

The increased demand for emergency admissions ran into two problems: 37 beds had disappeared and 50 were occupied through increased efficiency. The previous flexibility in the system no longer existed. The fact that such huge failures occurred in emergency admission systems across the country suggests similar bed management dynamics were operating in other hospitals which, like ours, were under huge pressure to meet waiting list targets and produce efficiency savings.

But why will the crisis turn into a disaster if current commissioning proposals are accepted by providers? We all recognise the effort the government has made to find money to invest in health services - and it is welcome.

However, what has received much less publicity is a parallel policy to cut costs in secondary care by 3 per cent a year for the next three years.

These are generally referred to as efficiency savings, and many politicians and commissioners appear to labour under the misapprehension that they are notional sums which do not represent real resources.

This mistake will further undermine the service. It will increase the caseload of each doctor, nurse and bed by attempting to reduce the cost of each patient's drugs, blood and investigations by what seems a trivial 3 per cent. It is unfair to ask hard-pressed staff to do this additional work.

Given the trust's financial performance, it seems impractical to take the alternative step and offer the HA the 3 per cent (in our case almost£3m), while accepting contracted activity at this year's performance levels.

Data has been published showing that the average number of patient discharges per nurse is around 30 per cent higher than it was five years ago. A similar exercise looking at the caseload of all physicians treating medical emergency cases - including elderly people - in Wolverhampton, shows a 25 per cent rise in the past four years. Such steep rises in caseload are not seen in general surgery, where emergency levels do not rise quickly.

These caseload increases are only one measure of the efficiency savings and cost cuts which have been the norm in the NHS for the past decade and have continued without any significant examination under the new government.

Such reductions have a pernicious effect on staff morale, workload and the quality and safety of patient care.

The message of the past few weeks is that the system came close to breakdown: reducing the resources available yet again can only spawn greater disaster.

As a medical director - first a doctor and second a manager - it seems to me a very real responsibility that I should ask commissioners how they can be confident that 3 per cent efficiency savings will not lead to breakdowns in the service. Nobody has provided me with evidence that the consequences of these cost savings are understood.

This message is a difficult one given the government's undoubted desire to improve NHS care. The conundrum was elegantly summarised by Aldous Huxley in Ends and Means in 1937: 'The end cannot justify the means, for the simple and obvious reason that the means employed determine the nature of the ends produced.'